<!-- Content Header (Page header) -->
<section class="content-header">
    <h1>
        Add New Member Data
    </h1>
    <ol class="breadcrumb">
        <li><a href="<?php echo base_url("admin_home");?>"><i class="fa fa-dashboard"></i> Home</a></li>
        <li><a href="<?php echo base_url("admin_member_ippi");?>">Member IPPI</a></li>
        <li class="active">Add</li>
    </ol>
</section>

<!-- Main content -->
<section class="content">
    <div class="loading">Loading&#8230;</div>
    <div class='row'>
        <div class='col-md-12'>
            <div class='box box-info'>
                <div class='box-header'>
                    <h3 class='box-title'>Data Form</h3>
                    <!-- tools box -->
                    <div class="pull-right box-tools">
                        <button class="btn btn-info btn-sm" data-widget='collapse' data-toggle="tooltip" title="Collapse"><i class="fa fa-minus"></i></button>
                        <!--<button class="btn btn-info btn-sm" data-widget='remove' data-toggle="tooltip" title="Remove"><i class="fa fa-times"></i></button>-->
                    </div><!-- /. tools -->
                </div><!-- /.box-header -->
                <div class='box-body pad'>
                    <div id="msg" class="alert alert-danger alert-dismissable">
                        <i class="fa fa-ban"></i>
                        <button type="button" class="close" data-dismiss="alert" aria-hidden="true">�</button>
                        <b>Alert!</b> Danger alert preview. This alert is dismissable. A wonderful serenity has taken possession of my entire soul, like these sweet mornings of spring which I enjoy with my whole heart.
                    </div>
                    <form role="form" action="<?php echo site_url();?>admin_member/add" method="post" id="frm_member_ippi_add">
                    <div class="row">
                        <form role="form" action="<?php echo site_url();?>admin_member_ippi/add" method="post" id="frm_member_ippi_add">
                            <div class="col-md-6">    
                                <div class="form-group">
                                    <label>Email</label>
                                    <input id="email" type="email" name="email" class="form-control" placeholder="Input member email" required=""/>
                                </div>
                                <div class="form-group">
                                    <label>Name</label>
                                    <input id="name" type="text" name="name" class="form-control" placeholder="Input member name"/>
                                </div>
                                <div class="form-group">
                                    <label>Alamat</label>
                                    <input id="alamat" type="text" name="alamat" class="form-control" placeholder="Input alamat"/>
                                </div>
                                <div class="form-group">
                                    <label>Province</label>
                                    <select class="form-control" id="province" name="province">
                                        <option value=""> - Pilih Provinsi - </option>
                                        <?php
                                    foreach ($list_state as $l) {
                                        ?>
                                        <option value="<?php echo $l->state_id;?>"><?php echo $l->state_name;?></option>
                                            <?php
                                    }
                                        ?>
                                    </select>
                                </div>
                                <div class="form-group">
                                    <label>Kota / Kebupaten</label>
                                    <div id="city_wrapper">
                                        <select class="form-control" id="city" name="city" disabled="">
                                            <option value=""> - Pilih Kabupaten - </option>
                                        </select>
                                    </div>
                                </div>
                                <div class="form-group">
                                    <label for="dtp_input1">Tanggal lahir</label><br/>
                                    <div style="padding-left: 0px;" class="input-group date form_datetime col-md-6" data-date="<?php echo date('Y-m-d'); ?>" data-date-format="yyyy-mm-dd HH:ii:ss" data-link-field="dtp_input1">
                                        <input id="tanggal_lahir_member"  class="form-control" size="16" type="text" value="" readonly="readonly" />
                                        <span class="input-group-addon">
                                            <span class="glyphicon glyphicon-remove"></span>
                                        </span>
                                        <span class="input-group-addon">
                                            <span class="glyphicon glyphicon-th"></span>
                                        </span>
                                    </div>
                                    <input type="hidden" name="tanggal_event" id="dtp_input1" value="" /><br/>
                                </div>
                                <div class="form-group">
                                    <label>Tempat Lahir</label>
                                    <input id="tempat_lahir" type="text" name="tempat_lahir" class="form-control" placeholder="Input tempat lahir"/>
                                </div>
                                <div class="form-group">
                                    <label>Pekerjaan</label>
                                    <input id="pekerjaan" type="text" name="pekerjaan" class="form-control" placeholder="Input pekerjaan member"/>
                                </div>
                                <div class="form-group">
                                    <label>Penghasilan rata-rata per bulan</label>
                                    <input id="income" type="text" name="income" class="form-control number" placeholder="Input penghasilan rata-rata"/>
                                </div>
                                <div class="form-group">
                                    <label>Pendidikan Terakhir</label>
                                    <select class="form-control" id="pendidikan" name="">
                                        <option value=""> - Pilih Pendidikan - </option>
                                        <option value="sd"> - SD - </option>
                                        <option value="smp"> - SMP - </option>
                                        <option value="sma"> - SMA - </option>
                                        <option value="d3"> - D3 - </option>
                                        <option value="s1"> - S1 - </option>
                                        <option value="s2"> - S2 - </option>
                                        <option value="s3"> - S3 - </option>
                                    </select>
                                </div>
                                <div class="form-group">
                                    <label>Telp Rumah</label>
                                    <input id="telp_rumah" type="text" name="name" class="form-control" placeholder="Input telp rumah (optional)"/>
                                </div>
                                <div class="form-group">
                                    <label>Telp Kantor</label>
                                    <input id="telp_kantor" type="text" name="name" class="form-control" placeholder="Input telp kantor (optional)"/>
                                </div>
                                <div class="form-group">
                                    <label>Hp</label>
                                    <input id="hp" type="text" name="name" class="form-control" placeholder="Input no Hp"/>
                                </div>
                                <div class="form-group">
                                    <label>Fax</label>
                                    <input id="fax" type="text" name="name" class="form-control" placeholder="Input no fax (optional)"/>
                                </div>
                                <div class="form-group">
                                    <label>Status Menikah</label>
                                    <select class="form-control" id="status_menikah" name="">
                                        <option value=""> - Pilih - </option>
                                        <option value="0"> - Belum Menikah - </option>
                                        <option value="1"> - Menikah - </option>
                                        <option value="1"> - Janda - </option>
                                    </select>
                                </div>
                                <div class="form-group">
                                    <label>Status VCT</label>
                                    <select class="form-control" id="status_vct" name="">
                                        <option value=""> - Pilih - </option>
                                        <option value="1"> Positif </option>
                                        <option value="0"> Negatif </option>
                                    </select>
                                </div>
                                <div class="form-group">
                                    <label>Tahun VCT Diketahui</label>
                                    <input id="tahun_vct" type="text" name="name" class="form-control number" placeholder="Input tahun VCT diketahui"/> 
                                </div>
                                <div class="form-group">
                                    <label>Status ARV</label>
                                    <select class="form-control" id="status_arv" name="">
                                        <option value=""> - Pilih - </option>
                                        <option value="0"> Belum ARV </option>
                                        <option value="1"> Lini 1 </option>
                                        <option value="2"> Lini 2 </option>
                                    </select>
                                </div>
                                <div class="form-group">
                                    <label>Jenis ARV</label>
                                    <input id="namejenis_arv" type="text" name="name" class="form-control" placeholder="Input jenis ARV"/> 
                                </div>
                                
                            </div>
                            <div class="col-md-6">    
                                <div class="form-group">
                                    <label>Jumlah Anak Laki-laki</label>
                                    <input id="jumlah_anak_laki" type="text" name="name" class="form-control number" placeholder="Input jumlah anak laki-laki"/> 
                                </div>
                                <div class="form-group">
                                    <label>Jumlah Anak Perempuan</label>
                                    <input id="jumlah_anak_pr" type="text" name="name" class="form-control number" placeholder="Input jumlah anak perempuan"/> 
                                </div>
                                <div class="form-group">
                                    <label for="dtp_input1">Tanggal lahir Anak ke 1</label><br/>
                                    <div style="padding-left: 0px;" class="input-group date form_datetime col-md-6" data-date="<?php echo date('Y-m-d'); ?>" data-date-format="yyyy-mm-dd HH:ii:ss" data-link-field="dtp_input1">
                                        <input id="tanggal_lahir_anak1"  class="form-control" size="16" type="text" value="" readonly="readonly" />
                                        <span class="input-group-addon">
                                            <span class="glyphicon glyphicon-remove"></span>
                                        </span>
                                        <span class="input-group-addon">
                                            <span class="glyphicon glyphicon-th"></span>
                                        </span>
                                    </div>
                                    <input type="hidden" name="tanggal_event" id="dtp_input1" value="" /><br/>
                                </div>
                                <div class="form-group">
                                    <label for="dtp_input1">Tanggal lahir Anak ke 2</label><br/>
                                    <div style="padding-left: 0px;" class="input-group date form_datetime col-md-6" data-date="<?php echo date('Y-m-d'); ?>" data-date-format="yyyy-mm-dd HH:ii:ss" data-link-field="dtp_input1">
                                        <input id="tanggal_lahir_anak2"  class="form-control" size="16" type="text" value="" readonly="readonly" />
                                        <span class="input-group-addon">
                                            <span class="glyphicon glyphicon-remove"></span>
                                        </span>
                                        <span class="input-group-addon">
                                            <span class="glyphicon glyphicon-th"></span>
                                        </span>
                                    </div>
                                    <input type="hidden" name="tanggal_event" id="dtp_input1" value="" /><br/>
                                </div>
                                <div class="form-group">
                                    <label for="dtp_input1">Tanggal lahir Anak ke 3</label><br/>
                                    <div style="padding-left: 0px;" class="input-group date form_datetime col-md-6" data-date="<?php echo date('Y-m-d'); ?>" data-date-format="yyyy-mm-dd HH:ii:ss" data-link-field="dtp_input1">
                                        <input id="tanggal_lahir_anak3"  class="form-control" size="16" type="text" value="" readonly="readonly" />
                                        <span class="input-group-addon">
                                            <span class="glyphicon glyphicon-remove"></span>
                                        </span>
                                        <span class="input-group-addon">
                                            <span class="glyphicon glyphicon-th"></span>
                                        </span>
                                    </div>
                                    <input type="hidden" name="tanggal_event" id="dtp_input1" value="" /><br/>
                                </div>
                                <div class="form-group">
                                    <label for="dtp_input1">Tanggal lahir Anak ke 4</label><br/>
                                    <div style="padding-left: 0px;" class="input-group date form_datetime col-md-6" data-date="<?php echo date('Y-m-d'); ?>" data-date-format="yyyy-mm-dd HH:ii:ss" data-link-field="dtp_input1">
                                        <input id="tanggal_lahir_anak4"  class="form-control" size="16" type="text" value="" readonly="readonly" />
                                        <span class="input-group-addon">
                                            <span class="glyphicon glyphicon-remove"></span>
                                        </span>
                                        <span class="input-group-addon">
                                            <span class="glyphicon glyphicon-th"></span>
                                        </span>
                                    </div>
                                    <input type="hidden" name="tanggal_event" id="dtp_input1" value="" /><br/>
                                </div>
                                <div class="form-group">
                                    <label>Nama Anak ke 1</label>
                                    <input id="nama_anak1" type="text" name="name" class="form-control" placeholder="Input Nama anak ke 1"/> 
                                </div>
                                <div class="form-group">
                                    <label>Nama Anak ke 2</label>
                                    <input id="nama_anak2" type="text" name="name" class="form-control" placeholder="Input Nama anak ke 2"/> 
                                </div>
                                <div class="form-group">
                                    <label>Nama Anak ke 3</label>
                                    <input id="nama_anak3" type="text" name="name" class="form-control" placeholder="Input Nama anak ke 3"/> 
                                </div>
                                <div class="form-group">
                                    <label>Nama Anak ke 4</label>
                                    <input id="nama_anak4" type="text" name="name" class="form-control" placeholder="Input Nama anak ke 4"/> 
                                </div>
                                <div class="form-group">
                                    <label>Pendidikan Anak</label>
                                    <select class="form-control" id="pendidikan_anak" name="">
                                        <option value=""> - Pilih Pendidikan - </option>
                                        <option value="sd"> - SD - </option>
                                        <option value="smp"> - SMP - </option>
                                        <option value="sma"> - SMA - </option>
                                        <option value="d3"> - D3 - </option>
                                        <option value="s1"> - S1 - </option>
                                        <option value="s2"> - S2 - </option>
                                        <option value="s3"> - S3 - </option>
                                    </select>
                                </div>
                            </div>
                            <div class="col-md-12">
                                <button type="submit" class="btn btn-primary">Submit</button>
                            </div>
                            
                    </div>
                        <div class="row">
                            <div class="col-md-12">
                                <div class="form-group" style="border-top: 1px dotted #ddd;padding-top: 20px;">
                                    <button type="submit" class="btn btn-primary">Submit</button>
                                </div>
                            </div>
                        </div>
                    </form>
                </div>
            </div><!-- /.box -->
        </div><!-- /.col-->
    </div><!-- ./row -->



</section><!-- /.content -->
